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Endotracheal intubation is a common lifesaving procedure that often is performed outside the operating room in a variety of clinical scenarios. Providers who perform intubation outside the operating room have variable degrees of training, skill development, and experience. A large number of studies were published in 2023 on the topic of intubations outside the operating room across a wide variety of settings and patient populations. Here, we review relevant papers on this topic published in 2023. [ABSTRACT FROM AUTHOR]

Operating rooms (ORs) use energy-intensive equipment such as anesthesia gas machines, patient monitors, and lights. They are major contributors to an institution's carbon footprint; yet ORs are unoccupied 40% of the time. Implementing an initiative to power down electrical devices can reduce energy consumption, equipment failure, and financial outlay. This quality improvement project developed and implemented a power down initiative for anesthesia staff to use in ORs. The initiative included turning off anesthesia gas machines, patient monitors, auxiliary oxygen delivery, and room lights at the end of scheduled cases in ORs that were not used for emergencies. Convenience audits were conducted. Pre- and postimplementation compliance outcomes showed that there was an increase in powering down the anesthesia gas machine, patient monitor, auxiliary oxygen, and room lights. Powering down unnecessary equipment at this facility has the potential to save approximately $50,000 and prevent the emission of over 80 metric tons of CO2 per year. Other facilities can implement a similar quality improvement project aimed at fiscal and ecological conservation. [ABSTRACT FROM AUTHOR]

Background: Anesthesiology has a relevant carbon footprint, mainly due to volatile anesthetics (scope 1 emissions). Additionally, energy used in the operating theater (scope 2 emissions) contributes to anesthesia-related greenhouse gas (GHG) emissions. Objectives: Optimizing the electricity use of medical devices might reduce both GHG emissions and costs might hold potential to reduce anaesthesia-related GHG-emissions and costs. We analyzed the electricity consumption of six different anesthesia workstations, calculated their GHG emissions and electricity costs and investigated the potential to reduce emissions and cost by using the devices in a more efficient way. Methods: Power consumption (active power in watt , W) was measured with the devices off, in standby mode, or fully on with the measuring instrument SecuLife ST. Devices studied were: Dräger Primus, Löwenstein Medical LeonPlus, Getinge Flow C, Getinge Flow E, GE Carestation 750 and GE Aisys. Calculations of GHG emissions were made with different emission factors, ranging from very low (0.09 kg CO2-equivalent/kWh) to very high (0.660 kg CO2-equivalent/kWh). Calculations of electricity cost were made assuming a price of 0.25 € per kWh. Results: Power consumption during operation varied from 58 W (GE CareStation 750) to 136 W (Dräger Primus). In standby, the devices consumed between 88% and 93% of the electricity needed during use. The annual electricity consumption to run 96 devices in a large clinical department ranges between 45 and 105 Megawatt-hours (MWh) when the devices are left in standby during off hours. If 80% of the devices are switched off during off hours, between 20 and 46 MWh can be saved per year in a single institution. At the average emission factor of our hospital, this electricity saving corresponds to a reduction of GHG emissions between 8.5 and 19.8 tons CO2-equivalent. At the assumed prices, a cost reduction between 5000 € and 11,600 € could be achieved by this intervention. Conclusion: The power consumption varies considerably between the different types of anesthesia workstations. All devices exhibit a high electricity consumption in standby mode. Avoiding standby mode during off hours can save energy and thus GHG emissions and cost. The reductions in GHG emissions and electricity cost that can be achieved with this intervention in a large anesthesiology department are modest. Compared with GHG emissions generated by volatile anesthetics, particularly desflurane, optimization of electricity consumption of anesthesia workstations holds a much smaller potential to reduce the carbon footprint of anesthesia; however, as switching off anesthesia workstations overnight is relatively effortless, this behavioral change should be encouraged from both an ecological and economical point of view. [ABSTRACT FROM AUTHOR]

Background: Studies show that workspace for the anesthesia providers is prone to interruptions and distractions. Anesthesia providers experience difficulties while performing critical medication tasks such as medication preparation and administration due to poor ergonomics and configurations of workspace, equipment clutter, and limited space which ultimately may impact patient safety, length of surgery, and cost of care delivery. Therefore, improving design of anesthesia workspace for supporting safe and efficient medication practices is paramount. Objectives: The objective of this study was to develop a set of evidence-based design guidelines focusing on design of anesthesia workspace to support safer anesthesia medication tasks in operating rooms (ORs). Methods: Data collection was based on literature review, observation, and coding of more than 30 prerecorded videos of outpatient surgical procedures to identify challenges experienced by anesthesia providers while performing medication tasks. Guidelines were then reviewed and validated using short survey. Results: Findings are summarized into seven evidence-based design guidelines, including (1) locate critical tasks within a primary field of vision, (2) eliminate travel into and through the anesthesia zone (for other staff), (3) identify and demarcate a distinct anesthesia zone with adequate space for the anesthesia provider, (4) optimize the ability to reposition/reconfigure the anesthesia workspace, (5) minimize clutter from equipment, (6) provide adequate and appropriately positioned surfaces for medication preparation and administration, and (7) optimize task and surface lighting. Conclusion: This study finds many areas for improving design of ORs. Improvements of anesthesia work area will call for contribution and cooperation of entire surgical team. [ABSTRACT FROM AUTHOR]

With increasing waiting lists across the UK for oral surgery under general anaesthesia (GA), inhalation sedation (IS) may provide the answer for patients to be treated more quickly. The authors believe it is an underused technique for the management of anxious and medically compromised patients requiring oral surgery. This article demonstrates, with patient examples, how IS can be used effectively. [ABSTRACT FROM AUTHOR]

BACKGROUND: Sedation is fundamental to the management of patients in the intensive care unit (ICU). Its indications in the ICU are vast, including the facilitating of mechanical ventilation, permitting invasive procedures, and managing anxiety and agitation. Inhaled sedation with halogenated agents, such as isoflurane or sevoflurane, is now feasible in ICU patients using dedicated devices/systems. Its use may reduce adverse events and improve ICU outcomes compared to conventional intravenous (IV) sedation in the ICU. This review examined the effectiveness of inhalational sedation using the anesthetic conserving device (ACD) compared to standard IV sedation for adult patients in ICU and highlights the technical aspects of its functioning. METHODS: We searched the PubMed, Cochrane Central Register of Controlled Trials, The Cochrane Library, MEDLINE, Web of Science, and Sage Journals databases using the terms "anesthetic conserving device," "Anaconda," "sedation" and "intensive care unit" in randomized clinical studies that were performed between 2012 and 2022 and compared volatile sedation using an ACD with IV sedation in terms of time to extubation, duration of mechanical ventilation, and lengths of ICU and hospital stay. RESULTS: Nine trials were included. Volatile sedation (sevoflurane or isoflurane) administered through an ACD shortened the awakening time compared to IV sedation (midazolam or propofol). CONCLUSION: Compared to IV sedation, volatile sedation administered through an ACD in the ICU shortened the awakening and extubation times, ICU length of stay, and duration of mechanical ventilation. More clinical trials that assess additional clinical outcomes on a large scale are needed. [ABSTRACT FROM AUTHOR]

Summary: Here, we present a case of mass ventilator failure due to contaminated medical air. Multiple ventilators failed routine tests, including almost all of the ventilators in our intensive care unit. A faulty air compressor had led to water contamination of our centre's supply of medical air. Water entered the pipeline supply of air and, hence the ventilators and anaesthetic machines. The disruption of the machines' proportional mixer valve resulted in unreliable delivery of fresh gas flow. This malfunction was discovered during routine pre‐use checks, and backup ventilators were available to replace the faulty ventilators. A shortage of equipment was averted due to a serendipitous availability of ventilator stockpiles prepared for the COVID‐19 pandemic. Ventilator shortages are commonly described in mass casualty and pandemic scenarios. While there are multiple strategies described in literature to augment and maximise equipment available for mechanical ventilation, stockpiling equipment remains an expensive but necessary component of disaster contingency planning. [ABSTRACT FROM AUTHOR]

Anesthesia technicians play a crucial yet often overlooked role in the operating room, supporting anesthesiologists and ensuring the safe delivery of anesthesia during surgical procedures. This abstract highlights the key responsibilities and contributions of anesthesia technicians, including preparation and setup, patient monitoring, assistance to anesthesiologists, emergency response, equipment maintenance, and team collaboration. [ABSTRACT FROM AUTHOR]

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Mechanical ventilation is ubiquitous in the operating room. This article explores the anesthesia machine as a ventilator, examining its unique features and differences from ventilators designed for long-term use. It will describe standard and nonstandard modes of ventilation. The reader will develop a more nuanced understanding of how to tailor ventilation and oxygenation strategies based on patient and anesthetic scenarios as well as with the assistance of new technologies. [ABSTRACT FROM AUTHOR]

Aim: Sedation is essential during invasive mechanical ventilation, and conventionally intravenous analgesic and sedative drugs are used. Sedation with inhaled anesthetics using anesthesia conserving device (ACD) is an alternative. There is no data on the safety and ease of use of AnaConDa™ from India. Materials and methods: After IEC approval and informed consent, we used AnaConDa™-S for Isoflurane sedation in 50 hemodynamically stable (need for <0.5 ng/kg/min of Noradrenaline infusion), ASA I and II patients aged 18-80 years, undergoing elective mechanical ventilation for up to 24 hours after elective oncosurgeries. Patients with mental obtundation (GCS <14), or if pregnant, were excluded. The primary outcome was time spent between RASS scores of -3 and -4, while secondary outcomes were incidence of delirium, technical problems with AnaConDa™, and adverse systemic effects of isoflurane. Bolus doses of isoflurane 0.2-0.5 mL were given if the Richmond agitation sedation scale (RASS) score was not achieved. Results: Fifty patients received isoflurane infusion for a median of 720 (IQR 630-900) minutes, and all remained in the target sedation range. Median time to awakening [19 (IQR, 5-85) minutes], to follow simple verbal commands [20 (IQR 5-180) minutes], and extubation after stopping the infusion of isoflurane was quick [100 (10-470) minutes]. All patients remained hemodynamically stable. None of the patients had delirium. Conclusion: Target sedation levels were achieved with initial boluses of isoflurane using AnaConDa™-S. Isoflurane sedation delivery using AnaConDa™-S is safe and feasible. [ABSTRACT FROM AUTHOR]

Background: Patients at risk of malignant hyperthermia need trigger-free anesthesia. Therefore, anesthesia machines prepared for safe use in predisposed patients should be free of volatile anesthetics. The washout time depends on the composition of rubber and plastic in the anesthesia machine. Therefore, new anesthesia machines should be evaluated regarding the safe preparation for trigger-free anesthesia. This study investigates wash out procedures of volatile anesthetics for two new anesthetic workstations: Dräger Atlan A350 and General Electric Healthcare (GE) Carestation 650 and compare it with preparation using activated charcoal filters (ACF). Methods: A Dräger Atlan and a Carestation 650 were contaminated with 4% sevoflurane for 90 min. The machines were decontaminated with method (M1): using ACF, method 2 (M2): a wash out method that included exchange of internal parts, breathing circuits and soda lime canister followed by ventilating a test lung using a preliminary protocol provided by Dräger or method 3 (M3): a universal wash out instruction of GE, method 4 (M4): M3 plus exchange of breathing system and bellows. Decontamination was followed by a simulated trigger-free ventilation. All experiments were repeated with 8% desflurane contaminated machines. Volatile anesthetics were detected with a closed gas loop high-resolution ion mobility spectrometer with gas chromatographic pre-separation attached to the bacterial filter of the breathing circuits. Primary outcome was time until < 5 ppm of volatile anesthetics and total preparation time. Results: Time to < 5 ppm for the Atlan was 17 min (desflurane) and 50 min (sevoflurane), wash out continued for a total of 60 min according to protocol resulting in a total preparation time of 96-122 min. The Carestation needed 66 min (desflurane) and 24 min (sevoflurane) which could be abbreviated to 24 min (desflurane) if breathing system and bellows were changed. Total preparation time was 30-73 min. When using active charcoal filters time to < 5 ppm was 0 min for both machines, and total preparation time < 5 min. Conclusion: Both wash out protocols resulted in a significant reduction of trace gas concentrations. However, due to the complexity of the protocols and prolonged total preparation time, feasibility in clinical practice remains questionable. Especially when time is limited preparation of the anesthetic machines using ACF remain superior. [ABSTRACT FROM AUTHOR]

Background: The surge of critically ill patients due to the coronavirus disease-2019 (COVID-19) overwhelmed critical care capacity in areas of northern Italy. Anesthesia machines have been used as alternatives to traditional ICU mechanical ventilators. However, the outcomes for patients with COVID-19 respiratory failure cared for with Anesthesia Machines is currently unknow. We hypothesized that COVID-19 patients receiving care with Anesthesia Machines would have worse outcomes compared to standard practice. Methods: We designed a retrospective study of patients admitted with a confirmed COVID-19 diagnosis at a large tertiary urban hospital in northern Italy. Two care units were included: a 27-bed standard ICU and a 15-bed temporary unit emergently opened in an operating room setting. Intubated patients assigned to Anesthesia Machines (AM group) were compared to a control cohort treated with standard mechanical ventilators (ICU-VENT group). Outcomes were assessed at 60-day follow-up. A multivariable Cox regression analysis of risk factors between survivors and non-survivors was conducted to determine the adjusted risk of death for patients assigned to AM group. Results: Complete daily data from 89 mechanically ventilated patients consecutively admitted to the two units were analyzed. Seventeen patients were included in the AM group, whereas 72 were in the ICU-VENT group. Disease severity and intensity of treatment were comparable between the two groups. The 60-day mortality was significantly higher in the AM group compared to the ICU-vent group (12/17 vs. 27/72, 70.6% vs. 37.5%, respectively, p = 0.016). Allocation to AM group was associated with a significantly increased risk of death after adjusting for covariates (HR 4.05, 95% CI: 1.75–9.33, p = 0.001). Several incidents and complications were reported with Anesthesia Machine care, raising safety concerns. Conclusions: Our results support the hypothesis that care associated with the use of Anesthesia Machines is inadequate to provide long-term critical care to patients with COVID-19. Added safety risks must be considered if no other option is available to treat severely ill patients during the ongoing pandemic. Clinical trial number: Not applicable. [ABSTRACT FROM AUTHOR]

The coronavirus disease 2019 (COVID-19) respiratory illness has increased the amount of people needing airway rescue and the support of mechanical ventilators. In doing so, the pandemic has increased the demand of healthcare professionals to manage these critically ill individuals. Certified Registered Nurse Anesthetists (CRNAs), who are trained experts in airway management and mechanical ventilation with experience in intensive care units (ICUs), rise to this challenge. However, many CRNAs may be unfamiliar with advancements in critical care ventilators. The purpose of this review is to provide a resource for CRNAs returning to the ICU to manage patients requiring invasive mechanical ventilation. The most common ventilator modes found in anesthesia machine ventilators and ICU ventilators are reviewed, as are the lung-protective ventilation strategies, including positive end-expiratory pressure, used to manage patients with COVID-19-induced acute respiratory distress syndrome. Adjuncts to mechanical ventilation, recruitment maneuvers, prone positioning, and extracorporeal membrane oxygenation are also reviewed. More research is needed concerning the management of COVID-19-infected patients, and CRNAs must become familiar with their ICU units' individual ventilator machine, but this brief review provides a good place to start for those returning to the ICU. [ABSTRACT FROM AUTHOR]

Access to surgical care and essential anesthesia is an integral part of universal health coverage. Also, increasing access to surgical care depends on a parallel increase in access to safe anesthesia. Today, five billion people (more than twothirds of the world's population) still do not have adequate, quality surgery and anesthesia care at the right time. Therefore, the World Federation of Societies of Anesthesiologists and the World Health Organization developed the International Standards for Safe Practice of Anesthesia. The standards include the following components, which are essential for the safety of patients undergoing surgical procedures: professional expertise, facilities and equipment, medications and intravenous fluids, monitoring, and anesthesia. In this article, it is emphasized that wherever and whenever possible, anesthesia should be provided, led, or overseen by an anesthesiologist. It is also strongly recommended that essential equipment is in place and adequate training to handle it safely has been provided. Unfortunately, some operating rooms of small hospitals and clinics does not meet the above standards. It may be difficult for each hospital to manage autonomously due to the lack of a unified checklist for essential standardized requirements. By introducing appropriate anesthesia safety standards in the operating rooms of small hospitals and surgery clinics, it will be possible to increase patient safety during surgery performed under general anesthesia, deep sedation, moderate sedation, or regional anesthesia. Through this process, it is expected that the mortality and morbidity rate of unexpected surgery patients can be minimized. [ABSTRACT FROM AUTHOR]

Prone positioning is frequently used for spinal surgery and is associated with risks including perioperative visual loss and stroke. Frequent eye checks and careful neck positioning are recommended. In our hospital's current model, anesthesia providers are required to kneel on the operating room floor beneath operating room table, exposing themselves to hazards such as bodily fluids and back and knee strain. This maneuver is both time consuming and unpleasant. While new devices that enable easier visualization of patients in the prone position exist, they are costly and not universally compatible with all operating room tables. Our objective for this feasibility pilot study was to determine if simple, extendable mirrors increase anesthetist comfort during these cases. A nonrandomized survey-based feasibility pilot study was performed, evaluating comfort while performing eye checks with extendable lighted mirrors compared to the standard kneeling practice. A total of 41 nurse anesthetists and anesthesiology residents were analyzed. A mixed model logistic regression demonstrates a three-fold improvement in comfort with the prone position after mirror use (OR = 3.34; 95% CI: 1.06–10.48; p = 0.039). The frequency of eye checks did not change significantly with introduction of the mirror. Use of the extendable mirror improves anesthesia provider comfort with patients in the prone position. We postulate that it may be a useful addition to our practice. [ABSTRACT FROM AUTHOR]

Anesthesia workspaces are integral components in the chains of many intraoperative bacterial transmission events resulting in surgical site infections (SSI). Matched cohort designs can be used to compare SSI rates among operating rooms (ORs) with or without capital equipment purchases (e.g., new anesthesia machines). Patients receiving care in intervention ORs (i.e., with installed capital equipment) are matched with similar patients receiving care in ORs lacking the intervention. We evaluate statistical power of an alternative design for clinical trials in which, instead, SSI incidences are compared directly among ORs (i.e., the ORs form the clusters) at single hospitals (e.g., the 5 ORs with bactericidal lights vs. the 5 other ORs). Data used for parameter estimates were SSI for 24 categories of procedures among 338 hospitals in the State of California, 2015. Estimated statistical power was ≅8.4% for detecting a reduction in the incidence of SSI from 3.6% to 2.4% over 1 year with 5 intervention ORs and 5 control ORs. For ≅80% statistical power, >20 such hospitals would be needed to complete a study in 1 year. Matched paired cluster designs pair similar ORs (e.g., 2 cardiac ORs, 1 to intervention and 1 to control). With 5 pairs, statistical power would be even less than the estimated 8.4%. Cluster designs (i.e., analyses by OR) are not suitable for comparing SSI among ORs at single hospitals. Even though matched cohort designs are non-randomized and thus have lesser validity, matching patients by their risk factors for SSI is more practical. [ABSTRACT FROM AUTHOR]

Background: The value of checking mask ventilation before administering neuromuscular blocking drugs is still debated.Method: We conducted a survey of the practice of anaesthetists in Sweden, first asking if they use a mask ventilation trial (MVT) as part of routine induction with intubation (not rapid sequence induction or expected difficult airway). We focused on the reasons for or against the MVT, probing the anaesthetists' attitudes in general but also in specific scenarios.Results: The response rate was 54%. We found that 65.1% routinely use a MVT, 21.4% sometimes do and 13.5% never do so. There was no effect for years of experience on the distribution. The most common reason for checking mask ventilation was "to gather information about the airway," while the reason for not using the MVT was mostly "that muscle relaxation often improves mask ventilation."Conclusion: We found several interesting comments about airway management at both practical and theoretical levels. The survey highlights that routinely performing a MVT is a common practice in Sweden in spite of the lack of evidence for increased patient safety. Future airway guidelines may need to address this practice. [ABSTRACT FROM AUTHOR]

Prolonged occupational exposure to waste anesthetic gases may have the potential to cause adverse health effects. Workplace exposure surveillance programs are intended to reduce health risk by evaluating exposures to waste anesthetic gases during surgical procedures. Both the personal breathing-zone and area measurements are used to assess occupational exposure in the operating theater. Direct-reading instruments provide real-time measurements and are useful for identifying leaks and evaluating on-the-spot corrective actions. Passive diffusion monitors quantify occupational exposures over time during surgery. The aim of this study was to evaluate a waste anesthetic gas surveillance program to understand occupational exposures and further improve data collection strategy. For this study, 76 survey reports from 2012 through 2014 were retrospectively reviewed to assess occupational exposures to isoflurane in 58 unique procedural rooms operated by the National Institutes of Health. The surveys included industrial hygiene assessments performed during animal and human surgical procedures. The survey reports were evaluated qualitatively and data from these reports was transcribed for quantitative analysis. Variations in sample strategy were observed between surveys and were attributed to ambiguity in the written surveillance program. The study also evaluated the relationship between isoflurane concentrations and sampling method, sampling location, patient type, or scavenging method. Isoflurane exposures were significantly higher among procedures performed on rodents compared to the patients with a large body mass (humans, non-human primates, and swine) (P < 0.05) and in procedures using the charcoal canister exhaust system compared with the central vacuum exhaust system. In addition, individuals performing the surgical procedure experienced elevated occupational exposures measured by both direct-reading instrument and passive diffusion monitors, that is, exposure was significantly higher as measured at the breathing-zone compared with any area within the room (P < 0.05). The study identified several inconsistencies and shortcomings in the surveillance program. Isoflurane concentrations measured during rodent procedures requires further review of work practices and engineering controls. Overall, the findings provide insights to further improve data collection, monitoring, and control of isoflurane exposures. [ABSTRACT FROM AUTHOR]

The purpose of this project was to determine the impact of double gloving during the induction of general anesthesia on the incidence of cross-contamination by the anesthesia provider. In a representative sample of anesthesia providers, induction sequences were initially evaluated using the providers' standard technique (group 0). The same providers were reevaluated after being educated on the double gloving technique (group 1). One month later the providers were reevaluated to identify which ones continued the double gloving technique (group 2). For each sequence, all providers were asked to complete a general anesthesia induction following a standard sequence (n = 30). Every anesthesia workstation was cleaned before each induction using the same supplies, and a black light was used to identify any contamination. The workstations included the anesthesia circuit/face mask, breathing bag, anesthesia machine (adjustable pressure-limiting valve/vaporizer), medication cart, intravenous (IV) stopcock, and IV fluid bag. Each group's workstation was evaluated before and after induction for foreign body changes. The 3 groups were compared using a related-samples Friedman test, which demonstrated that the double gloving technique significantly decreased contamination in most areas studied (P < .01). Use of a double gloving technique decreased cross-contamination by greater than 50%. [ABSTRACT FROM AUTHOR]

Total electrical power failure in the operating room is an uncommon event, but when it occurs, it poses a major threat to patient safety. Perhaps the most curable threat to patient safety is the lack of provider knowledge regarding what equipment capabilities will be lost and how long devices will function on battery power. The purpose of this project was to determine the internal battery-related capabilities and duration of function of site-specific anesthesia equipment during a total power failure and to develop a power failure protocol. Equipment capabilities and duration of function on internal battery power were assessed for several anesthesia gas machines (AGM), vital sign monitors, and intravenous infusion pumps. Testing revealed substantial differences in AGM battery life compared with the manufacturer's reference values. Vital sign monitors integral to the AGM failed immediately on simulation of a power failure, whereas portable vital sign monitors and infusion pumps functioned, on average, for 150 and 270 minutes, respectively. Because many devices relied on in the operating room do not operate or have reduced functional capability during a power failure, it is important to have a site-specific protocol to optimize patient care decision making in the event of a total power failure. [ABSTRACT FROM AUTHOR]

Clinical monitoring and technology are at the heart of anesthesiology, and new technological developments will help to define how anesthesiology will evolve as a profession. Anesthesia related research published in the JCMC in 2018 mainly pertained to ICU sedation with inhaled agents, anesthesia workstation technology, and monitoring of different aspects of depth of anesthesia. [ABSTRACT FROM AUTHOR]

Between 2002 and 2016, 806 million medical devices were recalled. When approving a device, the FDA employs advisory boards organized by medical specialty (e.g. cardiovascular) to make approval recommendations. Previous work has demonstrated high numbers of recalled orthopedic and cardiovascular devices; however, no prior studies have controlled for the number of approvals by advisory board. The purpose of this study is to identify device fields at higher risk for safety problems. This study compares specialty-specific, approval-adjusted recall rates of high-risk medical devices from 2002 to 2016 by utilizing publicly available FDA data on recalls and approvals. Devices approved under general hospital (113), anesthesiology (98), and cardiovascular (98) advisory boards constituted 71% of all class I recalls. For devices approved via the more rigorous pre-market approval pathway, those under the purview of the general hospital (0.25 recalls/approval, 95% Cl 0.15 - 0.41) advisory board had a significantly higher rate than average (p<0.05). For 510(k) cleared devices, microbiology (6.0 recalls/clearance, 95% Cl 3.4 - 10.6), anesthesiology (0.04 recalls/clearance, 95% Cl 0.03 - 0.04), general hospital (0.02 recalls/clearance, 95% Cl 0.02 - 0.02), and cardiovascular (0.010 recalls/ clearance, 0.009 to 0.015) advisory boards had significantly higher recall rates than average (p<0.05). Future regulatory resources should be directed towards device areas and approval pathways that pose a higher risk for safety problems. Sources of Funding: Northwestern University Department of Dematology's NAR Education and Research Fund-utilized for data analysis. Dr. Xu recognizes salary support from the Foglia Family Foundation and NIH NIAMS F32AR060710. Financial Disclosure: None [ABSTRACT FROM AUTHOR]

Operating room fires are rare but devastating events. Guidelines are available for the prevention and management of surgical fires; however, these recommendations are based on expert opinion and case series. The three components of an operating room fire are present in virtually all surgical procedures: an oxidizer (oxygen, nitrous oxide), an ignition source (i.e., laser, "Bovie"), and a fuel. This review analyzes each fire ingredient to determine the optimal clinical strategy to reduce the risk of fire. Surgical checklists, team training, and the specific management of an operating room fire are also reviewed. [ABSTRACT FROM AUTHOR]

This article examines successful management of an anesthesia machine failure with the Draeger (or Dräger) Apollo (Drager Inc) anesthesia workstation. Approximately 45 minutes into the case, while the patient was under general anesthesia and mechanical ventilation, the anesthesia machine failed to achieve positive pressurization following a high-pressure alarm. Despite multiple maneuvers, the issue did not resolve until the machine was manually powered off and on at the main power switch. This case report emphasizes the importance of always having a backup means of patient ventilation and anesthesia administration. [ABSTRACT FROM AUTHOR]

Background and Aims: Infection control is essential in anaesthetic practice for both personnel and equipment used. This study aims to evaluate knowledge of anaesthesiologists about infection control practices and to detect the pattern of anaesthetic devices contamination. Methods: Cross-sectional observational study at two university hospitals was done. Self-administered questionnaires were distributed to 80 anaesthesiologists and 90 nursing staff. Forty-four samples were taken from rigid laryngoscopes (22 pairs from handle and blade) for detection of bacterial or fungal contamination. Same laryngoscopes were tested for occult blood. Results: The response rate among the physicians was 72% while for nurses 94.4%. The responses were variable reflecting lack of adequate knowledge and unsatisfactory compliance to infection control practices. Tested samples showed no fungal growth. Fourteen (31.8%) samples were negative for bacteriological contamination and 5/44 (11.4%) showed gram-positive bacilli; gram-positive cocci were isolated from 12 samples (27.3%) where Staphylococcus epidermidis and Staphylococcus aureus, respectively, shared 18.2% and 9.1% of the total samples. Gram-negative bacilli were isolated from 13 samples (29.5%), of which Klebsiella spp. were most frequent (11.4%). Both Pseudomonas aeruginosa and Acinetobacter baumannii were isolated from 6.8% each. Citerobacter spp. was isolated from 4.5%. Occult blood was found in 45.5% of samples. Conclusion: The current study showed contamination of ready-to-use laryngoscopes in operative theatres and ICUs. [ABSTRACT FROM AUTHOR]

Intraoperative magnetic resonance imaging (MRI)-guided neurosurgery has gained popularity over the years globally. These surgeries require a dedicated operating room and MRI-compatible anaesthesia equipment. The anaesthesiologist providing care in this setup needs to be experienced and vigilant to ensure patient safety. Strict adherence to MRI safety checklists and regular personnel training would avoid potential accidents and life-threatening emergencies. Teamwork, good communication, preprocedure planning, and familiarity with the surroundings are very important for safe care and good outcomes. We performed a literature search in Google Scholar, PubMed and Cochrane databases for original and reviewed articles for the origins, development and applications of intraoperative MRI in neurosurgical procedures. Much of the research has emphasised on the surgical indications than the anaesthetic challenges faced during intraoperative MRI guided surgery. The purpose of this review is to discuss the anaesthetic concerns specific to this unique environment. [ABSTRACT FROM AUTHOR]

Background: Hand hygiene compliance scores in the anaesthetic department of an acute NHS hospital were persistently low. Aims: To determine the feasibility and validity of regular accurate measurement of HHC in anaesthetics and understand the context of care delivery, barriers and opportunities to improve compliance. Methods: The hand hygiene compliance of one anaesthetist was observed and noted by a senior infection control practitioner (ICP). This was compared to the World Health Organization five moments of hand hygiene and the organisation hand hygiene tool. Findings: In one sequence of 55 min, there were approximately 58 hand hygiene opportunities. The hand hygiene compliance rate was 16%. The frequency and speed of actions in certain periods of care delivery made compliance measurement difficult and potentially unreliable. During several activities, taking time to apply alcohol gel or wash hands would have put the patients at significant risk. Discussion: We concluded that hand hygiene compliance monitoring by direct observation was invalid and unreliable in this specialty. It is important that hand hygiene compliance is optimal in anaesthetics particularly before patient contact. Interventions which reduce environmental and patient contamination, such as cleaning the patient and environment, could ensure anaesthetists encounter fewer micro-organisms in this specialty. [ABSTRACT FROM AUTHOR]

The professional work of small animal veterinary staff encompasses a wide diversity of demanding tasks. This has prompted a number of studies covering physical, chemical, biological, ergonomic, or psychological hazards, as well as their health effects upon veterinary workers. However, such results were obtained from self-reported surveys (via paper or online). This study reports the identification of potential hazards and provides a risk assessment of 15 veterinary clinics based on data from walk-through surveys, interviews with workers, and quantification of indoor air quality parameters including concentration of volatile organic compounds (total, isoflurane, and glutaraldehyde). The risk arising from X-ray exposure was unacceptable in seven clinics; X-ray examination should be discontinued in the absence of isolated radiation rooms, poor safety practices, and lack of personal protective equipment. Ergonomic-related hazards and work practices should be revised as soon as possible, considering that improper postures, as well as moving and lifting heavy animals are major causes of musculoskeletal disorders. The risk levels were, in general, small or medium (acceptable) with regard to exposure to physical hazards (such as bites, scratches, cuts, and burns) and biological hazards. It was observed that the indoor air quality parameters including temperature, respirable particulate matter and total volatile organic compounds do not indicate a comfortable workplace environment, requiring clinics' attention to keep the safe environment. The veterinarians and nurses were exposed to isoflurane (above 2 ppm) during surgery if an extractor system for waste gas was used instead of a scavenging system. Finally, veterinary workers did not possess any type of training on occupational safety and health issues, even though they recognized its importance. [ABSTRACT FROM AUTHOR]

Background: A volatile anaesthetic (VA) reflector can reduce VA consumption (VAC) at the cost of fine control of its delivery and CO2 accumulation. A digital in-line vaporizer and a second CO2 absorber circumvent both of these limitations. We hypothesized that the combination of a VA reflector with an in-line vaporizer would yield substantial VA conservation, independent of fresh gas flow (FGF) in a circle circuit, and provide fine control of inspired VA concentrations.Method: Prospective observational study on six Yorkshire pigs. A secondary anaesthetic circuit consisting of a Y-piece with 2 one-way valves, an in-line vaporizer and a CO2 absorber in the inspiratory limb was connected to the patient's side of the VA reflector. The other side was connected to the Y-piece of a circle anaesthetic circuit. In six pigs, an inspired concentration of sevoflurane of 2.5% was maintained by the in-line vaporizer. We measured VAC at FGF of 1, 4 and 10 l/min.Results: With the secondary circuit, VAC was 55% less than with the circle system alone at FGF 1 l/min, and independent of FGF over the range of 1-10 l/min. Insertion of a CO2 absorber in the secondary circuit reduced Pet CO2 by 1.3-2.0 kpa (10-15 mmHg).Conclusion: A secondary circuit with reflector and in-line vaporizer provides highly efficient anaesthetic delivery, independent of FGF. A second CO2 absorber was necessary to scavenge the CO2 reflected by the anaesthetic reflector. This secondary circuit may turn any open circuit ventilator into an anaesthetic delivery unit. [ABSTRACT FROM AUTHOR]

The article focuses on the paediatric anaesthesia for low-resource settings among global health development community. It mentions the establishment of the Global Initiative for Emergency and Essential Surgical Care (GIEESC) by the World Health Organization (WHO) to strengthen delivery of anaesthesia and surgical care in low-income countries. It also mentions that high-quality perioperative care and outcomes are linked to the provision of safe anaesthesia.

Introduction Anesthesia machines have evolved to deliver desired tidal volumes more accurately by measuring breathing circuit compliance during a preuse self-test and then incorporating the compliance value when calculating expired tidal volume. The initial compliance value is utilized in tidal volume calculation regardless of whether the actual compliance of the breathing circuit changes during a case, as happens when corrugated circuit tubing is manually expanded after the preuse self-test but before patient use. We noticed that the anesthesia machine preuse self-test was usually performed on nonexpanded pediatric circuit tubing, and then the breathing circuit was subsequently expanded for clinical use. We aimed to demonstrate that performing the preuse self-test in that manner could lead to incorrectly displayed tidal volume on the anesthesia machine monitor. The goal of this quality improvement project was to change the usual practice and improve the accuracy of displayed tidal volume in infants undergoing general anesthesia. Methods There were four stages of the project: (i) gathering baseline data about the performance of the preuse self-test and using infant and adult test lungs to measure discrepancies of displayed tidal volumes when breathing circuit compliance was changed after the initial preuse self-test; (ii) gathering clinical data during pressure-controlled ventilation comparing anesthesia machine displayed tidal volume with actual spirometry tidal volume in patients less than 10 kg before (machine preuse self-test performed while the breathing circuit was nonexpanded) and after an intervention (machine preuse self-test performed after the breathing circuit was fully expanded); (iii) performing department-wide education to help implement practice change; (iv) gathering postintervention data to determine the prevalence of proper machine preuse self-test. Results At constant pressure-controlled ventilation through fully expanded circuit tubing, displayed tidal volume was 83% greater in the infant test lung (mean± SD TV 15±5 vs 9±4 mL; mean [95% CI] difference=6.3 [5.6, 7.1] mL, P<.0001) and 3% greater in the adult test lung (245±74 vs 241±72 mL; difference=5 [1, 10] mL, P=.0905) when circuit compliance had been measured with nonexpanded tubing compared to when circuit compliance was measured with fully expanded tubing. The clinical data in infants demonstrated that displayed tidal volume was 41% greater than actual tidal volume (difference of 10.4 [8.6, 12.2] mL) when the circuit was expanded after the preuse self-test (preintervention) and 7% greater (difference of 2.5 [0.7, 4.2] mL) in subjects when the circuit was expanded prior to the preuse self-test (postintervention) ( P<.0001). Clinical practice was changed following an intervention of departmental education: the preuse self-test was performed on expanded circuit tubing 11% of the time prior to the intervention and 100% following the intervention. Conclusion Performing a preuse self-test on a nonexpanded pediatric circuit that is then expanded leads to falsely elevated displayed tidal volume in infants less than 10 kg during pressure-controlled ventilation. Overestimation of reported tidal volume can be avoided by expanding the breathing circuit tubing to the length which will be used during a case prior to performing the anesthesia machine preuse self-test. After department-wide education and implementation, performing a correct preuse self-test is now the standard practice in our cardiac operating rooms. [ABSTRACT FROM AUTHOR]

The article looks at several studies related to circle systems and low-flow anesthesia. Topics covered include mathematical modelling as a significant tool for elucidating the function of circle systems, three rules for the safe use of circle systems, and a diagrammatic representation of a standard circle system.

Objective To evaluate oxygen flowmeters for accuracy and precision, assess the effects of cleaning and assess conformity to the American Society for Testing Materials (ASTM) standards. Study design Experimental study. Methods The flow of oxygen flowmeters from 31 anesthesia machines aged 1-45 years was measured before and after cleaning using a volumetric flow analyzer set at 0.5, 1.0, 2.0, 3.0, and 4.0 L minute-1. A general linear mixed models approach was used to assess flow accuracy and precision. Results: Flowmeters 1 year of age delivered accurate mean oxygen flows at all settings regardless of cleaning status. Flowmeters =5 years of age underdelivered at flows of 3.0 and 4.0 L minute-1. Flowmeters =12 years underdelivered at flows of 2.0, 3.0 and 4.0 L minute-1 prior to cleaning. There was no evidence of any beneficial effect of cleaning on accuracy of flowmeters 5-12 years of age (p > 0.22), but the accuracy of flowmeters =15 years of age was improved by cleaning (p < 0.05). Regardless of age, cleaning increased precision, decreasing flow variability by approximately 17%. Nine of 31 uncleaned flowmeters did not meet ASTM standards. After cleaning, a different set of nine flowmeters did not meet standards, including three that had met standards prior to cleaning. Conclusions Older flowmeters were more likely to underdeliver oxygen, especially at higher flows. Regardless of age, cleaning decreased flow variability, improving precision. However, flowmeters still may fail to meet ASTM standards, regardless of cleaning status. Clinical relevance Cleaning anesthesia machine oxygen flowmeters improved precision for all tested machines and partially corrected inaccuracies in flowmeters =15 years old. A notable proportion of flowmeters did not meet ASTM standards. Cleaning did not ensure that they subsequently conformed to ASTM standards. We recommend annual flow output validation to identify whether flowmeters are acceptable for continued clinical use. [ABSTRACT FROM AUTHOR]

This paper addresses the processes of boundary work, in relation to the introduction of new technology, unfolding during the emergence of new medical practices. Inspired by Gieryn's fluid and practical view of boundaries and boundary work, and by Actor-Network Theory's description of scripting processes, we study the processes of negotiating and (re-)constructing boundaries in order to reveal both the interactions between different kinds of boundary work and their situatedness in the context of the emerging practice. We conducted a longitudinal and qualitative study of a generic Hybrid Operating Room at a Swedish university hospital, where sophisticated imaging devices are combined with open surgery procedures in a single room; consequently, medical requirements regarding radiology, surgery and anesthesia, as well as the specificities of the new technology, all need to be met at the same time. The study shows how the visibility of boundaries is a result of as well as a condition for boundary work, how boundary work is a dynamic and iterative process, and how it unfolds in a recursive relationship between practice and boundaries. [ABSTRACT FROM AUTHOR]

The circle system has been in use for more than 100 years, whereas the first clinical application of an anaesthetic reflector was reported just 15 years ago. In the circle system, all breathing gas is rebreathed after carbon dioxide absorption. A reflector, on the other hand, with the breathing gas flowing to and fro, specifically retains the anaesthetic during expiration and resupplies it during the next inspiration. A high reflection efficiency (number of molecules resupplied/number of molecules exhaled, RE 80-90%) decreases consumption. In analogy to the fresh gas flow of a circle system, pulmonary clearance ((1-RE) × minute ventilation) defines the opposition between consumption and control of the concentration.It was not until reflection systems became available that volatile anaesthetics were used routinely in some intensive care units. Their advantages, such as easy handling, and better ventilatory capabilities of intensive care versus anaesthesia ventilators, were basic preconditions for this. Apart from AnaConDa™ (Sedana Medical, Uppsala, Sweden), the new MIRUS™ system (Pall Medical, Dreieich, Germany) represents a second, more sophisticated commercially available system.Organ protective effects, excellent control of sedation, and dose-dependent deep sedation while preserving spontaneous breathing with hardly any accumulation or induction of tolerance, make volatile anaesthetics an interesting alternative, especially for patients needing deep sedation or when intravenous drugs are no longer efficacious.But obviously, the outcome is most important. We know that deep intravenous sedation increases mortality, whereas inhalational sedation could prove beneficial. We now need prospective clinical trials examining mortality, but also the psychological outcome of those most critically ill patients sedated by inhalation or intravenously. [ABSTRACT FROM AUTHOR]

We compared implementation of systematic airway assessment with existing practice of airway assessment on prediction of difficult mask ventilation. Twenty-six departments were cluster-randomised to assess eleven risk factors for difficult airway management (intervention) or to continue with their existing airway assessment (control). In both groups, patients predicted as a difficult mask ventilation and/or difficult intubation were registered in the Danish Anaesthesia Database, with a notational summary of airway management. The trial's primary outcome was the respective incidence of unpredicted difficult and easy mask ventilation in the two groups. Among 94,006 patients undergoing mask ventilation, the incidence of unpredicted difficult mask ventilation in the intervention group was 0.91% and 0.88% in the control group; (OR) 0.98 (95% CI 0.66-1.44), p = 0.90. The incidence of patients predicted difficult to mask ventilate, but in fact found to be easy ('falsely predicted difficult') was 0.64% vs. 0.35% (intervention vs. control); OR 1.56 (1.01-2.42), p = 0.045. In the intervention group, 86.3% of all difficult mask ventilations were not predicted, compared with a higher proportion 91.2% in the control group, OR 0.61 (0.41-0.91), p = 0.016. The systematic intervention did not alter the overall incidence of unpredicted difficult mask ventilations, but of the patients who were found to be difficult to mask ventilate, the proportion predicted was higher in the intervention group than in the control group. However, this was at a 'cost' of increasing the number of mask ventilations falsely predicted to be difficult. [ABSTRACT FROM AUTHOR]